Ventricular Tachycardia and ST Elevation with Dr. B

Last Friday July 21, we had the privilege of learning about cardiology and ECGs from Dr. Baranchuk. As always, the session was super informative, fun, and interactive – I for one came away with a lot of great pearls! Dr. Baranchuk focused this session on the difference between ventricular tachycardia and torsades de pointes, as well as ST elevation in ACS vs Brugada syndrome. We had a few discussions about pacemakers and ICDs….but we’ll leave that for another session – stay tuned!

Check out the infographic below for a cursory overview of some of the important tidbits I took away from the session. Looking forward to the next one!

Heart Failure Risk Scale and Atrial Fibrillation

This week we had the pleasure of welcoming a guest speaker for grand rounds, prominent EM researcher and well-known clinical decision rule/tool expert from Ottawa, Dr. Ian Stiell. The focus of his talk was on the Canadian Heart Failure Risk Scale and atrial fibrillation, with some personal travel blogging and joking scattered throughout. Beginning with its derivation and subsequent validation, Dr. Stiell provided a background to the current phase of study that Queen’s will be a part of, the revision and validation of the Canadian Heart Failure Risk Scale. Approximately 1 million people are seen in the ED annually in Canada for acute heart failure, 40-60% of which are admitted to the hospital.  The Heart Failure Risk Score hopes to provide guidance and standardize practice for ED physicians across the country with respect to admission decisions in this population.  The group had a rich discussion about factors included, surprises found in the literature, and predicted utility of the tool. Dr. Stiell pointed out that in order to find out whether this tool will change practice, an implementation trial would have to ensue – stay tuned! In the meantime, check out the score and look for the bright yellow forms to fill out on your next shift in the ED!

The Canadian Heart Failure Risk Scale

Dr. Stiell finished his talk with a review of his work on management of acute atrial fibrillation and flutter. Refer to the updated Canadian CV Society Guidelines for the latest (see algorithm below). Dr. Stiell is now working with CAEP to adapt these guidelines to the ED – stay tuned!

BONUS feature: Dr. Stiell sold us on two new phone applications to check out – The Ottawa Rules Application and Thrombosis.

Thanks for coming Dr. Stiell (@EMO_Daddy)!

 

 

Mass Gatherings and ED Ultrasound

On February 2 we had the pleasure of welcoming back Dr. Colin Bell, a recent FRCP EM grad, all the way from Denver for a talk on ED Ultrasound and hearing some more stories from Dr. Terry O’Brien.

The legendary TOB started the morning off with a talk on mass gatherings, using the last Tragically Hip concert as an example. He took us through the planning, equipment, personnel involved, and lessons learned on the day. Our crew of one nurse (thanks Patti!), multiple residents, staff physicians, and essential administrative assistants provided excellent care and diverted 35 people away from the crowded hospital. EMS was instrumental in the success of the event as well. Kingston’s population received an additional 25, 000 that day!

Here are some resources on mass gatherings to take a look at in preparation for the next big event:

Colin Bell then took us through ‘The Second Phase of POCUS’, illustrating the growing utility of ED ultrasound with a few key cases in which management was altered based on bedside images. It is an exciting time for POCUS and is becoming more of an essential adjunct to diagnostic workups in the ED, especially when time is of utmost importance.

Don’t be shy to ask Colin about the cool new initiatives he is taking part in across the border – he also has some interesting stories to tell practicing EM in an entirely different context than we see here in Kingston.

Here is a reminder of a previous post in which we included a number of valuable online resources for ED ultrasound.

 

Thyroid Emergencies and CBME EPAs

On January 25th Dr. Andrew Hall gave us a reminder the concept of CBME and what it will look like next year. Dr. Heidi Wells followed with an excellent overview of Thyroid disorders encountered in the ED.

Andrew re-iterated the model of CBME and how it will fit into our emergency medicine program starting July 2017. He provided a list of the current entrustable professional activities (EPAs) for emergency medicine and a rich discussion ensued. Overall, it is an exciting time in medical education and Andrew convinced me that our already great program will only get better with this shift towards an outcomes-based, learner centered model! Feel free to ask Dr. Hall all about it, or refer to the PGME website for more information.

Heidi then took us through an approach to thyroid disorders in the ED – with tons of clinical pearls and important take home points to use on your next shift. See the infographic below for a summary of the key messages, and click here for a downloadable pdf version:

Interestingly, Queen’s wasn’t the only institution focused on thyroid disorders that week – the twittersphere was lighting it up!

In true FOAMed spirit, check these resources from the Bold City EM program in Jacksonville, Florida on endocrine, metabolic and nutrition themed topics. Thanks Bold City EM!

 

Journal club: Updates in Management of Ischemic Stroke and ATACH-2

Dr. Howes opened up his lovely home to host journal club this month on October 5, 2016 – it was an evening of pizza, ice cream, and enlightening discussion. As usual, two articles were featured. The commentary below, written by Kristen, was staff reviewed by Dan.

Endovascular thrombectomy after large vessel ischaemic stroke: a meta-analysis of individual patient data from five randomized trails 

by Goyal et al. published in the Lancet 2016.

Dr. Keegan Selby presented the resident chosen article listed above, providing an excellent summary of the “biggest thing to ever happen to neurology” in the context of current practices. To quote Dr. Rob Brison directly, the authors used a “really cool” technique to combine raw patient data from five previous studies, MR CLEAN, ESCAPE, SWIFT PRIME, REVASCAT, and EXTEND IA trials. It is amazing to see the possibilities with research collaboration such as this! We were lucky to have a strong staff presence to help us understand the basics of the mixed methods modelling used. The study is not a traditional meta-analysis and avoids much of the bias because patient level data was used and combined, rather than data that had already been sorted through and grouped. Importantly, authors did account for between-trial variation and were able to provide a more powerful and reliable conclusion than each individual study alone with these statistical techniques. Interestingly, the National Institute of Research is hoping to make all raw data available online from authors who publish under their grants in the future. Just think of the possibilities!

evt

In the end, we agree with the authors’ conclusion – EVT seems like a great idea to reduce disability in patients with large vessel anterior circulation ischemic strokes if you live close enough to a center proficient in this technique in a system that can afford it. Here in Kingston, we are capable – what remains to be determined is whether this is something that is feasible and ethical for KGH.

[Extra tidbit: 5 patients have undergone EVT at KGH – it is currently available during business hours to the optimal candidates. Bottom line: discuss with the stroke team if you encounter a patient with a large anterior ischemic stroke in the ED.]

 

Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage (ATACH-2) 

by Qureshi et al. published in NEJM 2016

Dr. Howes led the dialogue through the chosen staff article, ATACH-2 . The authors conducted a randomized, multicenter, open-label trial to examine the effects of intensive blood pressure control in acute cerebral hemorrhage, comparing a target of 110-140mmHg to 140-179mmHg using IV nicardipine – and stopped enrollment early due to futility after interim analysis. I won’t go into all of the details but we had rich discussion surrounding the standard treatment of acute cerebral hemorrhage at KGH, the generalizability of the data to our population, the generous enrollment criteria, the inadequate power of the study (keeping in mind it was stopped early), and the practical difficulty and reader uncertainty surrounding specifics of blood pressure control in this study. In the end, as the authors conclude, this will not change our current practice in the management of acute cerebral hemorrhage. A few take home points were emphasized that can be applied to any article:

  • Always look at the estimate of treatment effect – the authors used a very optimistic 10% difference in likelihood of death or disability at 3 months between their intervention and standard treatment to calculate the power needed at the outset of this study.
  • A superiority trial ≠ an equivalency trial ≠ an inferiority trial – refer to a previous post by Eve, Arrests and Ankles at Astors, for a refresher
  • Be alert to misleading conclusions – Dan used a personal anecdote of a indexspecial stuffed animal to remind us to avoid the “blue dog” false conclusion in our research and analyses; just because you don’t find blue dog in your search, does not mean that you can conclude for certain that blue dog is not in the house.

 

Grand Rounds: Pediatric Rashes

This week, Dr. Aaron Ruberto (otherwise known as Mr. Trebek), took us through an exciting and informative game of Jeopardy to teach us about Pediatric Rashes. The ultimate winner was Dr. Eve Purdy, but we all ‘won’ a ton of relevant and always difficult trivia regarding common and serious pediatric rashes encountered in the ED. See the infographic below as a reminder of the basics to use as an approach to these skin conditions in practice. If you have specific questions, I’m sure Aaron would be happy to provide his expert opinion.

gr-sept-29

You can download a pdf of the above summary here: Grand Rounds Sept 29.

You can also check out the following resources to practice your pediatric rashes:

Staff Rounds:

Dr. Nici Rocca presented an interesting case for staff rounds before Aaron took to the mic, reminding us to keep necrotizing fasciitis on our differential as one of the time sensitive, high mortality infections not to miss in the ED! She provided a description of a recent case she had in the ED of an older woman who presented with refractory cellulitis, pain out of proportion, and a history of femoral popliteal bypass. She reminded us of the risk factors (diabetes, vascular insufficiency, trauma, etc.), the physical exam (pain out of proportion, induration beyond visible cellulitis, crepitus, erythema, bullae, necrosis ecchymosis), and the importance of rapid referral to a surgeon as definitive treatment. Imaging can be done but should not delay treatment – CT or MRI are best. Piptazo + Vancomycin OR Clindamycin + Ampicillin + Vancomycin are good empiric regimes to start in the ED. Penicillin + Clindamycin can be used if you are sure it is a type 2 monomicrobial infection with streptococcus! In the end the patient above ended up having a graft infection for which she was placed on antibiotics and taken to the OR to remove the infected graft and repeat her bypass.

Journal Club: Sepsis and Syncope

Dr. Stephanie Sibley stepped up to the plate last-minute and saved the day to host our first journal club of the year on September 13! It turned out to be an excellent showing and invigorating discussion (from what I was able to see – unfortunately I missed most of the first article). Dr. Carly Hagel and Dr. Theresa Robertson led the discussion about the new sepsis guidelines, walking us through the latest publication, The third international consensus definitions for sepsis and septic shock (Sepsis-3). The authors used a variety of methods – database interrogation, systematic literature review, and Delphi consensus with expert critical care physicians to create new and improved definitions for sepsis, septic shock, and pathophysiology of the syndrome. The table below outlines their new and improved definitions.slide1SIRs is out and qSOFA is in…but is it useful for us?

The SOFA (sequential organ failure assessment) score is used in the ICU and is proposed by the task force as a means to clinically characterize a septic patient, not as a tool for management. The authors used database interrogation to identify a SOFA score of ≥2 as a predictor of increased mortality in patients with suspected infection. The quick bedside test that has been proposed to trigger rapid recognition and management in the ED is qSOFA…but it has not been validated outside of the ICU. [SIRS is now considered a tool to help clinicians to recognize infection in the first place, but does not represent a dysregulated response to such infection as occurs in sepsis (poor discriminant and concurrent validity).]

qsofa

Carly + Theresa’s conclusion:

The published conclusion states that the updated definitions and clinical criteria should clarify long used descriptors and facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing it. This conclusion is not supported by the data they quote. The SOFA is a predictor of mortality and has not been validated outside of the ICU setting. Nor has the qSOFA. Neither will facilitate earlier recognition – rather may be able to predict mortality in ICU patients.

The article chosen outlined the changes, but in order to find the selection criteria used for inclusion/exclusion of the specific databases used to support their work you will have to read the following:

It will be interesting to see where this new guideline goes and what discussion follows in the critical care, emergency, and hospital inpatient communities.

Syncope

The staff article chosen is one that we are all familiar with after filling out those pink sheets in the ED, involving our very own Dr. Marco Sivilotti: Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope. Dr. Sibley graciously hosted us in her amazing new place, sharing some statistical knowledge to give insight into the derivation process used to come up with this tool. The most important take away here for our practical purposes is that it is a derivation study. Before we put it to clinical use, it’s important to follow the next phase – validation. Once validated, this tool proposes to help the clinician to identify adult patients with syncope who are at risk of a serious adverse event within 30 days of disposition from the ED. Unlike most clinical tools that we are used to using, this one hopes to allow us to risk stratify patients who present with syncope who are considered both high and low risk by our clinical judgment. We had an interesting discussion as a group with the frustrations of syncope and what we thought about each of the factors included in the tool. Unfortunately he wasn’t able to attend, but feel free to probe Marco for more details – as usual he will have a wealth of information and opinions to share! For a users’ guide to clinical decision rules, see this JAMA article.

We eagerly await the next update on the Canadian Syncope Risk Score!

 

Summer Series: Lumbar Puncture, Suturing, and Pediatric Resuscitation

Last week’s summer series was an excellent session on lumbar punctures, suturing, and pediatric resuscitation.

Lumbar Puncture and Suturing

Dr. Eric Mutter and Dr. Karen Graham walked us through how to perform a lumbar puncture, both with and without ultrasound guided landmarking prior to the procedure – an especially useful skill in those patients whose anatomy or body habitus makes external landmarking more difficult. Dr. Sharleen Hoffe led a parallel session on suturing – reminding us of the basic principles of wound management and showing us some spiffy new techniques. It turns out that pigs feet are excellent models to practice skin and tendon repairs! Check out the infographic below for a summary of some important tidbits or click here to download the pdf: LP & Suturing.

Summer series LP:suture

For a more in depth look at extensor tendon repair, Sharleen directs us to this acep article.

Pediatric Resuscitation

We spent the afternoon in the SIM lab working through a series of pediatric resuscitation cases with Sharleen and Tim. This topic is a scary one for many of us and I found it very helpful to go over a few potential pediatric patients. Some take home points from the day were as follows:

  1. Use the broselow tape! Yell out the colour and estimated weight so that everyone is on the same page. If the child looks heavy for their age, increase the medication doses but keep the equipment sizes the same.
  2. Sepsis response is age related! Kids will often get hypocalcemic + hypoglycemic so watch out for those. In general, treat septic shock with norepinephrine if there is no response to 2 boluses of fluid. (Epinephrine is suggested instead of norepi in cases of “cold shock”)
  3. Remember to initiate CPR in the bradycardic kid with a pulse <60bpm.
  4. Intubation should be a last resort in asthmatics – just like in our adult population!
  5. Treat DKA with judicious fluids + skip the insulin bolus – we want to avoid cerebral edema if we can!
  6. Delegate math/dose calculations. You will have too many other things to think about running a resuscitation.
  7. Refer to the Canadian Pediatric Society Guidelines for a great overview of the most up to date expert recommendations.

Summer Series: Optho 101 and Procedural Sedation

Two weeks ago now (sorry for the delay), we had a great morning session from Dr. Rob Brison – let’s call it Rob’s optho 101. He started out at Hotel Dieu with some slit lamp tricks and tips – did you know that it takes 5-10 minutes for corneal abrasions to uptake fluorescein fully? Put it in early and complete the rest of your eye exam before using the cobalt blue setting. Remember to use it with all elderly patients with conjunctivitis – you may be surprised with what you find. We discussed conjunctivitis – allergic (bilateral, papillary pattern), viral (uni/bilateral, follicular pattern), and bacterial (purulent discharge, unilateral); and many other common eye complaints that we see in the ED. Take home points: (1) always use fluorescein (2) call optho when unsure or to arrange close follow up when concerned.

Check out this article by Rob published in 1993 on the utility of antibiotics in corneal abrasions.

 

Procedural Sedation

After lunch Dr. Caley Flynn and Dr. Eric Mutter (under the watchful eye of Dr. Jaelyn Caudle) taught us a thing or two about procedural sedation. See the infographic below for a crude summary, or click here : Procedural Sedation for a pdf to download.

Summer series PS

The discussion was rich and interactive. We worked through several examples of the ETCO2 tracings that we use to monitor our sedations in the ED – it’s definitely not as simple as it seems! For more practice, try out a few cases on capnography.com.

Additionally, two drugs that were not included in the infographic, but were discussed at rounds were ketofol (ketamine + propofol) and dexmedetomidine (Precedex). Ketofol is theoretically meant to be a combination that allows the use of a lower dose of each drug individually, therefore decreasing the incidence of adverse effects of both. Practice seemed to vary with few using the 1:1 combination, opting instead for a good dose of ketamine followed by a titrating dose of propofol as needed. For some further reading on this topic, check out David and Shipp 2011 and Andolfatto et al. 2012. Dexmedetomidine, on the other hand, is an EXPENSIVE alpha-2 agonist that provides “cooperative sedation” (analgesia + sedation + anxiolysis) and is widely used in the ICU. Caley and Eric predict that it may soon become more common in the ED, so stay tuned!

 

 

Journal Club: Asthma Exacerbations and high sensitivity troponins – is less really more?

Our last journal club of the year was held at Dr. Dagnone’s house in beautiful patio weather (sorry for the delay in posting), where we discussed dexamethasone versus prednisolone for pediatric asthma exacerbations as well as the implications of the new high sensitivity troponin assay.

A Randomized Trial of Single-Dose Dexamethasone Versus Multi-dose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department

by John J. Cronin et al. published recently in the Annals of Emergency Medicine Journal

Dr. Heather White and Dr. Nick Cornell lead the group through a critical look at the recent article in Annals of Emergency Medicine regarding optimal management of acute asthma exacerbations in children. This was an intention to treat, randomized, and open label non-inferiority study looking at single dose dexamethasone compared to 3 days of prednisolone for treatment of acute asthma exacerbations in children. The conclusion was that dexamethasone (0.3mg/kg) was found to be non-inferior to a 3 day course of prednisolone (1mg/kg/d) as measured by the mean PRAM score on day 4.

The discussion was rich and the consensus seemed to lean away from practice changing impact. Several concerns were raised with the study including the generalizability to our practice environment and the bias introduced with open label methodology. The study was done in Ireland using a 1mg/kg dose of prednisolone, which is typically dosed at 2mg/kg here up front in the ED followed by 1mg/kg/day at home. The PRAM score was felt to be a reasonable surrogate for asthma control and severity, but the exclusion criteria was extensive and we thought that the differences in PRAM would be difficult to pick up. In the end, for a child with mild-moderate asthma exacerbation who does not tolerate prednisolone, single dose oral dexamethasone is a reasonable choice!

forest plot

 

Derivation of a 2hr high-sensitivity troponin T algorithm for rapid rule-out of acute MI in ED chest pain patients

presented at CAEP 2016 by A McRae

The staff article this week was a very topical abstract presented at the 2016 CAEP conference by the University of Calgary’s Andy McRae. Dr. Colin Bell had a lot to add to Dr. Dagnone’s points after presenting a Grand Rounds on this topic earlier this year. Before going any further, the importance of knowing your own center was highlighted – at Kingston General Hospital, the lab is using the cTnI assay, which has increased sensitivity compared to the cTnT assay utilized in Calgary and the focus of the abstract.

The abstract described a study performed in Calgary to derive a 2-hr high sensitivity cTnT testing algorithm to rule out acute MI in ED chest pain patients. Their conclusion was that acute MI can be ruled out safely with a high sensitivity cTnT algorithm in 58.5% of chest pain patients within 2 hours of ED arrival. Apart from the obvious issue with a different assay, the logistics of the above mentioned time points in our ED, the definition of low risk chest pain and quantification of such, and the lower sensitivity of the algorithm for major adverse cardiac outcomes compared to acute MI made us all a little hesitant. The future sure looks promising, but we concluded that we’re yet ready for use of the 2-hr delta troponins across the board. It is probably okay for low risk chest pain patients, but the 6-hr test is definitely safer. Although there is lots more work to be done on this topic, the Calgary group has done a great job thus far and we’d like to congratulate them on the well deserved Grant Innes Research Award for top ranked CAEP abstracts this year in Quebec City!

Stop Colin or Damon next time you run into them to ask about their opinion – they have a wealth of information to share!

 

*as a useful side note, it came to light that a delta troponin (using our local cTnI assay) should only be considered different if it is >8